Refractive and visual outcome of hyperopic cataract cases operated on before and after implementation of the Holladay II formula

doi:10.1016/S0161-6420(98)99050-9

Ophthalmology

Volume 105, Issue 9, 1 September 1998, Pages 1759-1764

https://doi.org/10.1016/S0161-6420(98)99050-9 Get rights and content

Abstract

Objective

The primary objective was to evaluate the refractive and visual outcomes in a series of hyperopic cataract cases in which the Holladay II intraocular lens (IOL) power formula was used in conjunction with added eye measurements (measured anterior chamber depth [ACD], lens thickness, and corneal diameter) to improve predictability of refractive outcome. In addition, the impact of use of a double (“piggyback”) IOL on refractive outcome was evaluated.

Design

Prospective, nonrandomized comparative clinical trial.

Participants

A total of 136 consecutive hyperopic primary cataract-IOL cases operated on at in an outpatient eye surgery center were evaluated. The main inclusion criterion was the requirement of at least 30 D of emmetropia power.

Intervention

Implantation of a total implanted power calculated using a newly developed (Holladay II) formula, which uses additional eye measurements (measured ACD, lens thickness, corneal diameter) in addition to the axial length and keratometry normally used, was performed. In the first series, IOL powers were chosen using the Lloyd-Gills formula with modifiers; in the second series, powers were chosen using the Holladay II formula option in the Holladay IOL Consultant software. Selection criteria for both series were the same (requiring at least 30 diopters [D] of power for emmetropia). Keratometry and axial length measurements (by immersion) were taken using the same instrumentation and methodology in both series. Predicted postoperative refraction based on the IOL implanted and the method of power calculation used were computed for each case in both groups and compared to the actual achieved refraction.

Main outcomes measurements

Main clinical outcome parameters evaluated were the postoperative spherical equivalent (compared with the predicted spherical equivalent) and the best-corrected vision. These outcome parameters were evaluated within each surgical series, in the total group of cases (regardless of power calculation method). Further stratification according to the use of single or double implants also was done.

Results

In the group using an older formula system, mean preoperative spherical equivalent of 4.79 D was reduced to −0.67 D. Similarly, in the Holladay II group, the preoperative mean of 5.60 D was reduced to −0.58 D. However, there were fewer large deviations between predicted and achieved spherical equivalent in the Holladay II group as indicated by a smaller standard deviation of the absolute deviation (0.47 vs. 0.59), and the range of postoperative refractions was smaller with fewer large overcorrections or undercorrections. However, almost 90% of both groups were within a diopter of the predicted refraction. Visual results were comparable in the two groups.

Conclusion

Both IOL calculation systems showed good predictability in these extremely short eyes. The Holladay II formula was simpler because it is incorporated into a user-friendly software package (Holladay IOL Consultant) and required only the input of IOL constants and preoperative measurements with no “fudge factor” modifiers. Results within the series using this formula had a tendency toward a smaller standard deviation with fewer outliers.

Section snippets

Methods

This was a retrospective record study of two consecutive surgical series of hyperopic cataract patients with IOLs. Use of the Holladay II formula was implemented in February 1997. Working from the surgical log, a consecutive series of 69 hyperopic cataract cases was obtained that required 30 or more D of emmetropia power (Lloyd-Gills regression formula6 with empirically derived clinical modifiers). Next, a series of 67 consecutive hyperopic cases operated on after February were identified in

Power calculation

We used immersion biometry to measure axial length in all cases because it provides superior results.7 First, because the cornea is not applanated, the axial length is not reduced from the applanation. Although this small error is insignificant in longer eyes, in short eyes this small difference can lead to significant error in power calculation. Second, it allows visualization of the corneal echoes. Third, the consistency of echo heights results in more accurate measurement of axial length,

Results

A total of 136 cases were evaluated: 69 were operated on before use of the Holladay II formula and 67 after switching to the Holladay II formula. Refractive outcomes for each of the series and for all cases in total are presented in Table 1. In the series operated on before using the Holladay II formula, the mean preoperative spherical equivalent was 4.79 D, which was reduced to a mean of −0.67 D. The range of postoperative refraction was −5.63 to +2.5 D. Mean preoperative spherical equivalent

Discussion

Since the introduction of IOL surgery by Dr. Harold Ridley in 1949, there has been an ongoing effort to improve the accuracy of IOL calculation so that a desired postoperative refraction could be obtained consistently and predictably. As we know from history, Dr. Ridley’s early lens implants left his patients almost as myopic as they would have been hyperopic without the lens.

Early techniques of putting a fixed power lens in all eyes soon were adjusted by varying this power depending on the

References (14)

J.T. Holladay et al.
Achieving emmetropia in extremely short eyes with two piggyback posterior chamber intraocular lenses
Ophthalmology
(1996)
J.L. Gayton et al.
Implanting two posterior chamber intraocular lenses in a case of microphthalmos
J Cataract Refract Surg
(1993)
T. Olsen et al.
Intraocular lens power calculation with an improved anterior chamber depth prediction algorithm
J Cataract Refract Surg
(1995)
H.J. Shammas
A comparison of immersion and contact techniques for axial length measurement
J Am Intraocul Implant Soc
(1984)
K.J. Hoffer
The Hoffer Q formulaa comparison of theoretic and regression formulas
J Cataract Refract Surg
(1993)
J.T. Holladay et al.
A three-part system for refining intraocular lens power calculations
J Cataract Refract Surg
(1988)
W.A. Lyle et al.
Clear lens extraction for the correction of high refractive error
J Cataract Refract Surg
(1994)

There are more references available in the full text version of this article.

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To investigate the predictive value of the intracrystalline interphase point (ICIP) measured with optical low-coherence reflectometry (OCLR) to estimate the final lens position (FLP) of an intraocular lens (IOL) after cataract surgery.
Alcañiz Hospital, Teruel, Spain.
Single-center retrospective descriptive study.
Patients undergoing cataract surgery were enrolled. They were grouped according to the IOL implanted as follows: Group 1, Acrysof IQ aspheric SN60WF IOL (77 eyes); Group 2, enVista MX60 IOL (71 eyes); Group 3, CT Asphina 409 IOL (44 eyes). An OCLR-based biometer (Lenstar LS 900 system) was used for biometric measurements preoperatively and at 4 to 5 weeks postoperatively.
The study comprised 192 eyes of 174 patients (mean age: 76.4 years). One hundred seventy eyes (88.5%) eyes showed an absolute refractive prediction error (ARPE) less than 0.50 diopters (D). The mean ARPE was 0.25 D ± 0.21 (SD). Significantly higher FLP values were found in Group 2 compared with the other two groups (P < .001). Significantly lower ICIP values were found in the eyes with an ARPE of 0.50 D or more compared with eyes that had an ARPE less than 0.50 D in Group 1 (P = .042) and Group 2 (P = .023). The correlation of the FLP with the ICIP was good in all three groups (r ≥ 0.74, P <.001). Three linear expressions were obtained to predict the FLP from the ICIP and other preoperative data (R²: 0.85, 0.69, and 0.49 in Groups 1, 2, and 3, respectively).
The position of the ICIP measured with OCLR correlated with the FLP after cataract surgery, and it can be used to optimize IOL power calculations.
Updates on managements of pediatric cataract
2019, Journal of Current Ophthalmology
Citation Excerpt :
There was also new formula such as Holladay 2. Fenzl et al. found no more accuracy for Holladay 2 than Hoffer Q formula.102 In another study, predicted implant power by Holladay I and Haigis formula was similar to each other, and the SRK/T was comparable to these both.103
A comprehensive review in congenital cataract management can guide general ophthalmologists in managing such a difficult situation which remains a significant cause of preventable childhood blindness. This review will focus on surgical management, postoperative complications, and intraocular lens (IOL)-related controversies.
Electrical records of PubMed, Medline, Google Scholar, and Web of Science from January 1980 to August 2017 were explored using a combination of keywords: "Congenital", "Pediatric", "Childhood", "Cataract", "Lens opacity", "Management", "Surgery", "Complication", "Visual rehabilitation”, and "Lensectomy". A total number of 109 articles were selected for the review process.
This review article suggests that lens opacity obscuring the red reflex in preverbal children and visual acuity of less than 20/40 is an absolute indication for lens aspiration. For significant lens opacity that leads to a considerable risk of amblyopia, cataract surgery is recommended at 6 weeks of age for unilateral cataract and between 6 and 8 weeks of age for bilateral cases. The recommended approach in operation is lens aspiration via vitrector and posterior capsulotomy and anterior vitrectomy in children younger than six years, and IOL implantation could be considered in patients older than one year. Most articles suggested hydrophobic foldable acrylic posterior chamber intraocular lens (PCIOL) for pediatrics because of lower postoperative inflammation. Regarding the continuous ocular growth and biometric changes in pediatric patients, under correction of IOL power based on the child's age is an acceptable approach. Considering the effects of early and late postoperative complications on the visual outcome, timely detection, and management are of a pivotal importance. In the end, the main parts of post-operation visual rehabilitation are a refractive correction, treatment of concomitant amblyopia, and bifocal correction for children in school age.
The management of congenital cataracts stands to challenge for most surgeons because of visual development and ocular growth. Children undergoing cataract surgery must be followed lifelong for proper management of early and late postoperative complications. IOL implantation for infants less than 1 year is not recommended, and IOL insertion for children older than 2 years with sufficient capsular support is advised.
Cataract surgery in the small eye
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Citation Excerpt :
The Haigis requires the ACD, whereas the Holladay 2 requires ACD as well as WTW, lens thickness, refraction, and age. These fourth-generation formulas, in addition to the Hoffer Q, are preferred when doing IOL power calculations in small eyes.41–45 A recent study by Carifi et al.23 confirmed the superiority of the Hoffer Q, Holladay II, and Haigis formulas over the SRK/T and SRK II IOL formulas in small eyes.
The surgical management of cataract in the small eye presents the ophthalmic surgeon with numerous challenges. An understanding of the anatomic classification in addition to a thorough preoperative assessment will help individualize each case and enable the surgeon to better prepare for the obstacles that might be encountered during surgery. Small eyes are especially challenging in terms of intraocular lens (IOL) calculations and possible current limitations of available IOL powers, which could necessitate alternative means of achieving emmetropia. Surgical strategies for minimizing complications and maximizing good outcomes can be developed from knowledge of the anatomic differences between various small-eye conditions and the pathologies that may be associated with each. A thorough understanding of the challenges inherent in these cases and the management of intraoperative and postoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results.
No author has a financial or proprietary interest in any material or method mentioned.
Accuracy of the refractive prediction determined by multiple currently available intraocular lens power calculation formulas in small eyes
2015, American Journal of Ophthalmology
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Apart from accurate biometry, the use of highly powerful lenses demands a precise effective lens position prediction. The fourth-generation Holladay 2 and the third-generation Hoffer Q have been recommended in eyes with axial length shorter than 22.0 mm.12,18 More recently, Eom and associates have shown similar results obtained by the Hoffer Q and Haigis formula in their short-eyes series.30
To observe the refractive outcomes of cataract surgery in small adult eyes, and to investigate the accuracy of different intraocular lens (IOL) power prediction formulas.
Retrospective interventional case series.
We included consecutive small eyes undergoing uneventful phacoemulsification cataract surgery with a single highly powerful IOL (Acrysof SA60AT) implanted in the capsular bag (range of powers +35.0 to +40.0 diopters [D]), at the Cataract Centre for Moorfields Eye Hospital. Exclusion criteria were combined or previous intraocular surgical procedures, and any type of intraoperative complications. Main outcome measures were mean prediction errors with Hoffer Q, Holladay 1, Holladay 2, Haigis, SRK-T, and SRK-II IOL power prediction formulas and proportions of eyes achieving absolute errors within the dioptric ranges of 0.5, 1.0, and 2.0 D of target and emmetropia, respectively. The ANOVA test was used to compare the refractive results among various formulas.
Twenty-eight eyes were studied; the mean numerical error was 0.22 ± 1.22 D and the mean absolute error was 0.95 ± 0.78 D with the adopted Hoffer Q formula; 39%, 61%, and 89% of the eyes had a final refraction within 0.5 D, 1.0 D, and 2.0 D of target, respectively. None of the latest-generation formulas significantly outperformed the others (P = .245).
The Hoffer Q formula led to good or fair refractive outcomes in less than two thirds of the cases. With Holladay 1 and 2 and Haigis formulas, outcomes would have not been significantly different. The SRK formulas yielded less accurate predictions. Possible reasons are discussed.
Evaluation of predictability and refractive changes in pediatric pseudophakia
2013, Archivos de la Sociedad Espanola de Oftalmologia
Evaluar la predictibilidad de la refracción postoperatoria y la evolución refractiva en pseudofaquia pediátrica.
Trabajo prospectivo, longitudinal, en operados de catarata con lente intraocular, menores de 15 años, con 5 años continuos de seguimiento. Los pacientes fueron divididos según la edad en años al momento de la cirugía: grupos de 0 a 2 años, de 3 a 5 años, de 6 a 8 años y de 9 o más años. Se estudiaron error de predicción y cambio refractivo. Se realizó el análisis estadístico aplicando t de Student, test de Anova.
Se incluyeron 60 ojos (44 pacientes). Sin diferencias significativas entre grupo unilateral y bilateral. El error de predicción fue de 1,5 ± 1,8 D en el grupo de 0 a 2 años, significativamente mayor que en los otros grupos (ANOVA p = 0,01). El cambio refractivo a los 5 años del grupo de 0 a 2 años fue de -4,7 ± 3,4 D, (ANOVA p = 0,0002) mientras en los otros grupos fue significativamente menor y sin diferencias entre grupos.
El grupo de 0 a 2 años resultó menos hipermétrope de lo esperado, con un 100% dentro de lo aceptado de dos desviaciones estándar, pero con alta variabilidad. El cambio refractivo observado en este grupo coincide con trabajos previos en los que el mayor crecimiento y el aumento de la longitud axial ocurre durante los primeros dos años. El cálculo y utilización de una LIO en niños tiene mejor predicción refractiva inmediata y, a largo plazo, en mayores de 2 años de edad.
Evaluate the predictability of the postoperative refraction and refractive changes in pediatric pseudophakia.
Prospective, longitudinal follow-up on patients under the age of 15 years operated on for a cataract with intraocular lens, with 5 continuous years of follow-up. The patients were divided into 4 groups according to age at the time of the surgery: group from 0 to 2 years old, from 3 to 5 years old, from 6 to 8 years old, and 9 years and over. Error prediction and refractive change were studied. Statistical analysis was performed using the Student t and ANOVA test.
A total of 60 eyes were included (44 patients). No significant differences were found between the unilateral and bilateral group. The prediction error in the 0 to 2 years group was 1.5 ± 1.8 D, significantly higher than in the other groups (ANOVA P = .01). Refractive change in 5 years of the group of 0 to 2 years was -4.7 ± 3.4 D (ANOVA P = .0002), while in the other groups it was significantly lower, with no differences between them.
The 0 to 2 years group was less hyperopic than expected, 100% within the accepted of 2 standard deviations, but with a high variability. The refractive change observed in this group coincides with previous reports that the largest growth and increase in axial length occurs during the first 2 years. The calculation and use of an IOL in children has a better immediate refractive prediction, and at long term in those older than 2 years of age.
Accuracy of modern intraocular lens power calculation formulas in refractive lens exchange for high myopia and high hyperopia
2009, Journal of Cataract and Refractive Surgery
Citation Excerpt :
These results tend to be better than those reported in previous studies17,28–33 (Table 4B). Fink et al.,31 Siganos and Pallikaris,30 and Fenzl et al.33 found similar results in cases of hyperopic cataract or refractive lens procedures for the Holladay 231,33 and SRK/T30 formulas, respectively. Hoffer17 found very similar results for the Hoffer Q and Holladay 2 formulas in eyes with an AL shorter than 22.0 mm (mean error 0.719 D and 0.713 D, respectively).
To determine the accuracy of the Holladay 2, Hoffer Q, SRK/T, and Haigis intraocular lens (IOL) power calculation formulas in high myopic and high hyperopic refractive lens exchange (RLE) with hydrophobic acrylic foldable IOLs.
Department of Ophthalmology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
Preoperatively, axial length (AL) was measured by partial coherence interferometry with the IOLMaster. The RLE was performed by phacoemulsification with posterior chamber IOL implantation in the capsular bag. Optimization of the lens constants for each IOL type was done separately for eyes with a positive lens and eyes with a negative lens. Prediction error (predicted refraction − postoperative refraction) and mean absolute error were back-calculated for the Holladay 2, Hoffer Q, SRK/T, and Haigis formulas.
Sixty-three eyes (44 myopic, AL ≥26.0 mm; 19 hyperopic, AL ≤22.0 mm) were included. In myopic and hyperopic RLE, all 4 formulas had an overall good performance. In myopic RLE, the Haigis formula performed better.
In myopic and hyperopic RLE, optimization of lens constants improved the accuracy of IOL power calculation.

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Refractive and visual outcome of hyperopic cataract cases operated on before and after implementation of the Holladay II formula

Abstract

Objective

Design

Participants

Intervention

Main outcomes measurements

Results

Conclusion

Section snippets

Methods

Power calculation

Results

Discussion

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

J Am Intraocul Implant Soc

J Cataract Refract Surg

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J Cataract Refract Surg